Thursday, June 28, 2012

By upholding the Affordable Care Act (aka “Obamacare”), the Supreme Court set aside the greatest single existential threat to the law: a finding that some or all of the law is unconstitutional. A ruling against it could have delayed achievement of the goal of providing near-universal health insurance coverage for at least another generation. More immediately, it would have introduced chaos into the system, as I blogged about (and CNN reported on today with a link to a KevinMD retweet of my post) back in April. A mixed verdict—overturning the health insurance mandate but keeping most of the rest of it—would have raised a whole host of practical concerns, including whether the subsidies, exchanges and insurance market rules survive with it.

As it was, the Supreme Court upheld the individual insurance requirement—defined as a “tax” in the majority opinion written by Chief Justice Roberts. Check out the SCOTUS blog for an excellent PLAIN ENGLISH explanation of the individual insurance ruling.

On Medicaid, though, the court upheld the part of the law that expands Medicaid to cover people up to 133 percent of the Federal Poverty Level—but removed the main penalty available for the federal government if a state doesn’t comply, which would have been a cutoff of all existing federal Medicaid dollars to non-compliant states. Instead, it leaves the “carrot” (more federal dollars for Medicaid: 100 percent initially, declining to 90 percent) but not the “stick” of a complete loss of Medicaid funds. This leaves the door open that some states will decline to expand their Medicaid programs to all of the poor and near-poor as the ACA intended.

Overall, though, the decision gives a green light to the ACA, meaning that the federal and state governments have no constitutional or legal reason to further delay implementation of the health insurance subsidies, insurance market reforms, individual insurance subsidies, essential benefits packages, delivery system reforms, or Medicare benefit improvements—that is, just about everything in the law.

As a result, the Supreme Court decision should result in tens of millions fewer uninsured persons in 2014, some 16 million through subsidized private health insurance, and up to another 17 million on Medicaid, depending on how many states go along with the Medicaid expansion. ACP, a long-time champion of universal health insurance coverage, said in a statement released today that the Supreme Court decision is a “victory for improving health care for all Americans.”

The law continues to face formidable challenges, however. Republicans insist that they will do everything in their power to repeal it, or at least to try to deny needed funding so as to slow down or impede its implementation. They won’t get too far, because the Senate and White House won’t go along. But the 2012 elections could change all of that.

It remains to be seen if the states—especially the 26 that brought the unsuccessful constitutional challenge to the Supreme Court—will continue to resist setting up the heath exchanges and preparing for more Medicaid patients, perhaps until after the 2012 elections, even though delay could put them in the precarious position of inviting the federal government to run their exchange if they haven’t made enough progress on their own by early next year. Governor Bob McDonnell of Virginia, chair of the Republican Governors Association, told NBC news that states are “stuck” with the law “at least until we see if we have a new Senate and a new president.”

Finally, the biggest challenge is that President Obama, congressional Democrats, and organizations that support the ACA have not yet persuaded a solid majority of the public on its merits. While large majorities favor many of the law’s specific improvements, “Fewer than half of Americans have supported the law in every major poll since its passage. A significant portion of this opposition comes from those who say the law did not go far enough,” according to a Washington Post article. The individual insurance requirement is supported by less than a third of the public.

Still, despite the challenges, today is a day to celebrate the fact that Supreme Court ruled in a way that will allow most of the law to go forward, moving us closer to the goalpost of universal health insurance access for all and better consumer protections and benefits for everyone.

Today’s question: What is your reaction to the Supreme Court decision? What do you think it means for the future of the ACA?

An hour ago, the Supreme Court upheld all of the key provisions of the ACA. And CNN’s report on the decision referenced and included a link to KevinMD’s reposting of my blog on the chaos for doctors and patients had the law been overturned!

I will have more to say about this decision in a posting later today, but it will surprise none of my regular readers that I view this as a huge win for doctors and their patients.

Monday, June 25, 2012

Another anti-climatic day in Washington, and still no decision from the Supreme Court of the United States (sometimes referred to as SCOTUS) on the constitutional challenges to the Affordable Care Act. But we now know one thing for sure: the decision will be coming out on Thursday, likely between 10 and 11 a.m. EDT—the last day of the court’s session. ACP will review the decision and be ready with a public response within hours, so check this blog for my and ACP’s reaction later in the day. I will also tweet about the decision (@bobdohertyACP) within minutes of the ruling.

In the meantime, I have pulled together the following links to help frame the issues that are at stake, including reprising some of my own blog posts:

--The Washington Post’s Sarah Kliff has a great post that concisely explains the issues being considered by the Court and potential ramifications.

--And, her colleague Ezra Klein has another outstanding post on 11 facts about the Affordable Care Act. With all of the distortions and misrepresentations poisoning the debate, it is good to have someone set the record straight.

--One of the challenges being considered by the Court is whether the expansion of Medicaid is unconstitutional. While the Court won’t be considering the merits of the Medicaid program—it will only rule on whether the federal government has over-reached by requiring states to cover all persons with incomes up to 133% of the Federal Poverty level—a new study shows that when uninsured persons get covered by Medicaid, they see marked gains in their health care. Among other gains, they are far more likely to report having better health and far more likely to have a relationship with a primary care physician than their uninsured counterparts. So much for the policy argument that Medicaid coverage really doesn’t help people get better health care.

--My blog post on what we stand to lose if the Court overturns the entire law. And the chaos that could ensue for physicians and their patients.

Finally, on twitter, @bobdohertyACP, I take on the Heritage foundation over its five reasons why Obamacare is bad for doctors, answering with ten real reasons, supported by real evidence, on why the law is good for doctors and good for patients:
1. Nearly everyone will have health insurance, saving tens of thousands of lives each year.
2. Patients no longer will be denied coverage or charged excessively because of health.
3. Patients and doctors are empowered with better information on the effectiveness of different treatment options.
4: Primary care doctors get more than 11 billion in higher Medicare Medicaid payments.
5: Millions more for scholarships and loan repayment for primary care doctors in undeserved areas.
6: Seniors receive no-cost prevention and wellness exams and reduced drug costs, saving them an average of $20,000.
7: Medicare will pay primary care doctors more for coordinating care.
8. Insurers must spend more on patient care, less on administration, or give rebates.
9: No more annual and lifetime limits on coverage = no one goes broke because of health.
10: Ensuring that everyone has health insurance is the morally, clinically and economically right thing to do.

None of these benefits or consequences may be particularly relevant to the Supreme Court, and people are so dug in on their opinion of the law that facts and evidence may not make a difference in their views. But it is important for all of us to remember what really is at stake for patients and physicians when the Court rules on Thursday—and when Congress, the administration, and voters decide what to do next.

Today’s questions: What do you expect the Supreme Court to do? And what do you think the impact will be?

Monday, June 18, 2012

What will a Supreme Court ruling against the Affordable Care Act mean for health care? The answer, actually, is pretty simple: veterans, seniors, people with pre-existing conditions, primary care doctors, people who buy coverage from the individual insurance market, children and adults with pre-existing conditions, and of course the uninsured, are among the tens of millions of Americans will lose out if the ACA goes away.

For the past several weeks, I have been tweeting (under the hash tag #WhatWeLOSEifObamacareGoes) about who will lose out, and what they will lose, if the ACA is overturned. Here is a partial list, drawn from credible studies and news reports:

40 MILLION seniors on Medicare will spend an average of $20,000 more out of their own pockets for medical care and prescriptions.

The 47% of us who do not get needed screening tests and wellness examinations will face new barriers because insurers no longer will be required to cover preventive services at no cost to the patient.

Many more of us will end up having to get care from over-crowded emergency rooms.

And, of course, 32 MILLION uninsured persons—many of them from the working poor—will lose access to affordable health insurance coverage.

Elimination of the ACA will also have a negative impact on the economy in many states: California alone will lose100,000 JOBS and 1.4 billion in ECONOMIC OUTPUT.

But I think the greatest thing we will lose is the chance to finally, after a century of trying and failing, do the right thing and ensure that all of us, no matter where we live or work or how much we earn or how healthy or unhealthy we are, will have access to affordable health insurance coverage. If the ACA goes away, I see no chance that Congress will enact a replacement plan to ensure coverage for all, at least not for another decade or so. And that will be to our lasting shame as a country.

Today’s questions: Who do you think we lose the most if the ACA goes away? And if we lose our chance now to provide coverage to nearly all Americans, when do you think Congress will take the issue up again?

Monday, June 4, 2012

The medical profession has always been marked by division: town versus gown, primary care versus specialty medicine, states versus national. But the real fault line today is not defined by specialty, geography, or teaching versus practice, but by size of practice.

Physicians in smaller practices, without regard to specialty or where they are located, are embattled and defensive—and therefore are more skeptical when someone tries to peddle the need for delivery system reform. This is a generalization, but my observation is that physicians in smaller practices see Accountable Care Organizations and Patient-Centered Medical Homes as a threat, and physicians in larger practices them more as an opportunity. Physicians in smaller practices prefer to keep fee-for-service, even as they complain that it doesn’t pay them fairly for their services, while physicians in larger practices (many of whom already are salaried or paid on a productivity + FFS model basis) are more likely to be willing to leave FFS behind.

There is evidence that physicians in smaller practices are also more likely to have a more anti-government, conservative political orientation than those in larger groups. The New York Times reported last year that "as more doctors move from business owner to shift worker, their historic alliance with the Republican Party is weakening from Maine as well as South Dakota, Arizona and Oregon, according to doctors’ advocates in those and other states."

There also may be some self-selection bias at work: physicians who choose to own or work in smaller practices may be more individualistic by nature and therefore less trusting of being "managed"—by government, by health plans, or even by other physicians—and therefore are more conservative in their political leanings and more adversarial towards government.

Of course, even if this generally is true, there are many exceptions: I know very liberal doctors in solo or small practices, and very conservative ones in very large practices.

Sometimes, the practice-size divide is mirrored in specialty society politics. I am told that ophthalmologists and dermatologists tend to be in smaller practices, and their national medical specialty societies tend to be more conservative on their approach to health care and delivery system reforms.

Interestingly, though, a 2009 report by the well-respected Center for Studying Health System Change did not find much variation in reported career satisfaction associated with practice size, with more than 75 percent of all physicians reporting that they were "very satisfied" or "somewhat satisfied" with their careers in all categories of practice size (solo, 3-5, 6-50, 51 plus, HMO, and institutional practice).

Physicians in smaller practices also tend to be older—and that may also be correlated with a more conservative view of government. Two years ago, I provocatively asked in a blog post "Is it too late for small practices?" citing an AMA survey that found that "75.5 percent of physicians are office-based (61.1 percent owner, 14.4 percent office-based employee), and that this percentage increases with age, from 68.9 percent for physicians under 40 to 81.2 percent for physicians over 54."

I concluded then, and still believe, that there is a future for smaller practices—but that they will need to adapt to be successful:

"I think that that the physician practices that do well in the future will be those that are able to demonstrate to buyers of health care that they are able to provide measurable "value" for the money being spent, defined as good or better outcomes at lower cost. With the right mix of supportive public policy and trusted advice and practical resources to help them succeed, I believe that the future for smaller practices may be much brighter than conventional wisdom suggests."

Here’s the problem, though: telling a physician in a smaller practice that they need to adapt is about as popular as a teetotaler preaching abstinence in an Irish bar! Plus, "adapting" or "practice transformation" usually sounds like someone else telling them to spend money they don’t have, to invest in something that they don’t believe in (ACOs, PCMHs), in the (futile?) hope that someone will pay them at least enough to cover their costs—so they at best end up breaking even for all of the effort. So what’s the point?

And I can’t disagree with them—so far, the return on investment for medical homes and some of the other new models being rolled out are marginal and uncertain at best, although for the first time the government is beginning to put some real money on the table for medical homes in its Comprehensive Primary Care Initiative.

But here’s the rub: "adapting" or "transforming" is risky, but what is the alternative? The movement to more integration and bigger sized enterprises has affected every other part of the American economy—how many locally-owned "Mom and Pop" restaurants or pharmacies are there in your neighborhood? And the small businesses that do survive have had to adapt.

There is a great, locally-owned book store in my neighborhood, Politics and Prose, that not only has survived the "big box" bookstores (even as a Borders less than a mile away went down with the rest of the chain), but is hanging on (so far) through the e-books onslaught. They have done it by great outreach to the community, by regularly hosting authors and poets for readings and discussion, and by helping you find any book you want, whether they carry it or not. Think of it as a Reader-Centered Literary Home! But they also have survived because they serve a small but prosperous niche market of readers (who still prefer real books).

The challenge for an advocacy organization like ACP is that we have members on both sides of the fault line. And no matter how effective our advocacy is for smaller practices (we’re always looking at proposed rules and laws from the standpoint of "How will they affect our members in smaller practices?" and "How can we help them succeed?"), we can’t turn back larger economic forces that have led just about every other cottage industry to either go out of business or find new strategies to adapt.

Today’s question: Do you agree that "small" versus "large" is the new fault line in American medicine, and if so, how can ACP navigate it effectively?